Healthcare Provider Details

I. General information

NPI: 1811945926
Provider Name (Legal Business Name): RICHARD JOHNSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S WASHINGTON AVE
MARSHALL TX
75670-5336
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-1488
  • Fax:
Mailing address:
  • Phone: 800-394-4445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number613247
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP110601
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: